ch. 19: nursing care during labor Flashcards
What are the characteristics of TRUE LABOR CTXS?
-produce progressive dilation and effacement of cervix
-occur REGULARLY and INCREASE in frequency, duration, and intensity
Are TRUE LABOR ctxs relieved by comfort measures?
no
Where are TRUE LABOR CTXs felt?
in LOWER BACK radiating to LOWER ABD
What are the characteristics of FLASE LABOR CTXs?
occurs IRREGULARLY and STOPS with walking or position changes
can FALSE LABOR ctxs be STOPPED by comfort measures?
yes
Where are FALSE LABOR CTXs felt?
in the back or abd ABOVE THE NAVEL
When can AROM be performed?
when fetus HEAD IS ENGAGED
What is done IMMEDIATELY after AROM?
check FHR: the cord may be displaced by the sudden “gush” of waters which may yield a prolapsed cord
What are the different PHASES of STAGE 1 of labor?
1) latent phase
2) active phase
3) transition phase
The FIRST stage of labor begins with the onset of _____ and ends w/ complete cervical ____ & ____
The FIRST stage of labor begins with the onset of UTERINE CONTRACTIONS and ends w/ complete cervical EFFACEMENT & DILATION
How much does the CERVIX DILATE during the LATENT PHASE of stage 1 of labor?
0-3 cm
How FREQUENT are the CTXs during the LATENT PHASE of stage 1 of labor?
every 5-30 mins
What is the MOTHER’S RESPONSE during the LATENT PHASE of stage 1?
-surge of ENERGY & EXCITEMENT
-talkative, outgoing
-low anxiety
When is the BEST time to TEACHING?
-during the latent phase of stage 1
What is IMPORTANT to remind mothers during the first stage of labor?
DO NOT PUSH during first stage bc it can cause CERVICAL EDEMA
-can also cause cervical lacerations and fetal hypoxia
How much does the cervix DILATE during the ACTIVE PHASE of stage 1?
4-7 cm
How FREQUENT are the CTXs during the ACTIVE PHASE of stage 1?
every 2-5 mins
What is the MOTHER’S RESPONSE during the ACTIVE PHASE of stage 1?
-more serious
-determined, dependent, desires companionship
-RESTLESS
-FOCUSED ON SELF
How much does the cervix DILATE during the TRANSITION PHASE of stage 1?
7-10 cm
How FREQUENT are the CTXs during the TRANSITION PHASE of stage 1?
every 2-3 mins
What is the MOTHER’S RESPONSE during the TRANSITION PHASE of stage 1?
-AMNESIA btwn ctxs
-nausea. trembling of legs
-irritable, aggressive, frustration, fear, loss of control
-urge to push
-perspiration on upper lip and forehead
-shaking tremor of thighs
-feeling NEED to DEFECATE
What type of emotional support can you provide?
-offer support and explanation
-encouragement
-breathing and relaxation techniques
The second stage of labor is where the infant is_______
BORN
The SECOND stage of labor begins w/ full cervical _____ & complete ____. It ends w/ the ____
The SECOND stage of labor begins w/ full cervical DILATION (10 cm) & complete EFFACEMENT (100%). It ends w/ the BABYS BIRTH
What is the second stage of labor also called?
“delivery or expulsive stage”
How much is the cervix dilated during the SECOND stage of labor?
10 cm
How FREQUENT are the CTXs during the SECOND STAGE of labor?
every 2-5 mins
What is the MOTHER’S RESPONSE during the SECOND STAGE of labor?
-sweat on upper lip
-episode of vomiting
-increase in bloody show
-shaking
-restlessness
-pressure on rectum, involuntary bearing down
-bulging of perineum
When is the pt INSTRUCTED to push?
once dilation and effacement are complete, theyre instructed to PUSH w/ each CTX and REST btwn them
The THIRD stage of labor lasts from the _____ until the ____
The THIRD stage of labor lasts from the BIRTH OF THE BABY until the PLACENTA IS EXPELLED
What is the THIRD stage of labor also called?
“placental” stage
How does the uterus shape change during STAGE 3 of labor?
from DISCOID to GLOBULAR
What are signs of placental separation?
-firmly contracting fundus
-uterus shape from DISCOID to GLOBULAR
-sudden gush of dark blood from introitus
-lengthening of umbilical cord
-uterus rises in abd
The THIRD stage of labor lasts from the _____ until the ____no longer tends to relax
The THIRD stage of labor lasts from the DELIVERY OF THE PLACENTA until the UTERUS no longer tends to relax
What is the 4th stage of labor called?
the RECOVERY STAGE
What can retention of tissues in the uterus lead to?
can lead to uterine atony and cause HEMORRHAGE
What can you do to ensure that the fundus remains contracted?
massage it gently
What are the benefits of breastfeeding during the FOURTH stage of labor?
-triggers release of oxytocin which lets down milk and causes uterine ctxs
-allows mom and infant to bond
What should you ASSESS the PERINEUM for during the 4th stage of labor?
Redness
Edema
Ecchymosis
Drainage
Approximation
What should you provide for the mother’s perineum after delivery?
an ice pack
What is LOCHIA?
maternal discharge of blood, mucus, and tissue from the uterus
-can last up to several weeks after birth
The FOURTH stage of labor is considered to be the first _____ after birth.
The FOURTH stage of labor is considered to be the first 1 to 2 HRS AFTER BIRTH after birth.
What happens during the 4th stage of labor?
mother and newborn recover from the physical process of labor and get to know each other
What FACTORS can influence the DURATION of the second stage of labor?
-presentation of fetus
-fetus position
-size of fetus
=parity of mom
-sedation
-force and frequency of ctxs
-anxiety
-emotional state
How can you TEST fluid to determine if it is amniotic fluid or urine when there is a possble SROM?
-nitrazine test for ph of fluid
-AMNIOTIC FLUID IS ALKALINE (> 6.5 pH)
-normal body fluids are ACIDIC
What are POTENTIAL COMPLICATIONS of the laboring pt?
-hemorrhage
-infection
-FHR bradycardia or late decels
